Skin Care Form

*First Name
*Last Name
*Email
*Describe your skin texture
*Have you ever had a facial?
*How often do you get facials? When was your last facial?	required
*What are your skin care goals?	required
*What concerns you most about your skin? (Choose one here, type others below.)
*List other concerns about your skin	required
*What concerns you most about your eyes? (Choose one here, type others below.)
*List other concerns about your eyes	required
*Have you had any of the following advance facial procedures? (Choose one here, type others below.)
*List other advance facial procedures & give approx dates for these & the one above	required
*Have you been under the care of a dermatologist or plastic surgeon in past year & why?	required
*Have you ever used any of these advance skin care items? (Choose one here, type others below.)
*List other advance skin care items used & give approx dates for these & the one above	required
*How often do you cleanse your face?
*Do you use a sunscreen? If so, which spf?
*Do you sunbathe?
*How much sun exposure do you receive?
*When are you most exposed to the sun?
*Do you use tanning booths now?
*What are your sleeping habits?
*Have you had any waxing or electrolysis of your face in the past week?	required
*Have you ever reacted to a skin care product or cosmetic before?
*If yes, what kind of reaction, what part of face, which product brand?	required
*Do you have breakouts around your period?
*Do you have any metal implants in your body? (i.e. pacemaker, copper IUD, dental fillings, etc)	required
*Do you use SOAP on your face daily or occasionally? List brand name.	required
*Do you use CLEANSING CREAM daily or occasionally? List brand name.	required
*Do you use CLEANSING LOTION daily or occasionally? List brand name.	required
*Do you use ASTRINGENT daily or occasionally? List brand name.	required
*Do you use TONER daily or occasionally? List brand name.	required
*Do you use MOISTURIZER daily or occasionally? List brand name.	required
*Do you use EYE CREAM daily or occasionally? List brand name.	required
*Do you use FACIAL SCRUB / PEEL daily or occasionally? List brand name.	required
*Do you use FACIAL MASK daily or occasionally? List brand name.	required
*Do you use ESSENTIAL OIL on your face daily or occasionally? List brand name.	required
*Do you use a SPECIAL TREATMENT PRODUCT daily or occasionally? List brand name.	required
*Do you use RETIN-A daily or occasionally? List brand name.	required
*Do you use AHA (alphahydroxy acid) daily or occasionally? List brand name.	required

Skin Care Form

Love Thyself Day Spa

Love Thyself Day Spa

972 644 4065